1. Have you had any experience with arm and trunk lymphedema being affected by a diep surgery?

Answer: Lymphedema in the breast cancer patient is caused by removal of axillary lymph nodes with subsequent inflammation and scar formation in the axilla. Radiation therapy further increases the chance of lymphedema. DIEP flap breast reconstruction does not result in more scarring in the axilla and should not cause or aggravate lympedema. With approximately 2000 DIEP breast reconstructions over the past 20 years, no patient has developed lymphedema as a side effect of this surgery.

In 2003 I began vascularized lymph node transfer to the axilla to reduce or eliminate lymphedema. In 2006 I combined the DIEP flap with lymph nodes the restore form and function by reconstructing the breast and treating the lymphedema in one operation. At an international microsurgery symposium I met Corinne Becker, MD. She has been successfully treating lymphedema with vascularized lymph node transfer for many years and is the world leader in this area.

The lady who posed the question is a candidate for combined DIEP/lymphnode transfer to restore both form and function.

2. We would love for you to explain the evolution of the DIEP since we all respect that you were the first surgeon to do these as far back as the 80’s and 90’s.

Answer: The ideal tissue for breast reconstruction lies transversely across the lower abdomen. The quality and permanence of autogenous breast reconstruction is far superior to implant reconstruction. My goal was to discover the best donor site with the least risk to the patient.

The TRAM flap of the early 1980’s was able to make a natural breast without implants, but the abdomen suffered from sacrifice of the rectus abdominus muscles. In 1989 I began investigating the blood supply to the lower abdominal skin and fat. I first concentrated on the superficial inferior epigastric blood vessels. By injecting the superficial inferior epigastric artery(SIEA) on fresh abdominoplasty specimens, I concluded that the skin and fat of the lower abdomen could be transferred using microsurgical techniques to reconstruct a breast without sacrifice of the abdominal muscles. The first cases went great, but I realized some patients either did not have a superficial artery or it was too small. I briefly abandoned the SIEA procedure and began doing free TRAM flaps. Unfortunately the free TRAM resulted in hernias, weakness, and pain. I re-examined the blood supply of the lower abdomen concentrating on the deep inferior epigastric system. By injecting a single dominant perforator of the deep inferior epigastric artery, I demonstrated that this could be used to transfer the lower abdominal skin and fat.

Thus was born the DIEP flap for breast reconstruction in August 1992 at Charity Hospital in New Orleans. As Director and later Chief of the Plastic Surgery Residency Program at Louisiana State University Medical Center until Hurricane Katrina in 2005, I trained one or two Fellows a year in Microsurgical Bresast Reconstruction. Since then I have trained 12 Fellows at the Medical University of South Carolina and New York University Medical Center.

3. What is the current status of nerve transplants for nipple sensation after reconstruction and do you see advances coming in the near future?

Answer: The sensory nerves to the nipple arise from the intercostal nerves coming off the spinal cord traveling on the under surface of the ribs. They give off posterior branches in the axilla and anterior branches just lateral to the sternum. We often dissect the 4th and/or 5th posterior intercostal nerves for 5 to 7 centimeters at the time of mastectomy. A sensory nerve on the DIEP flap can be connected to the breast nipple nerve to restore sensation to the new breast. Also the anterior branch can be coapted to the DIEP sensory nerve. Even without a nerve repair, the sensory nerves slowly grow into the DIEP flap resulting in some sensation in most patients over 12-24 months.

Most of my patients today have nipple sparing mastectomies. It is very important for the Breast Oncologic Surgeon to spare the medial intercostal nerves and blood vessels during the mastectomy. The most important one arises between the 2nd and 3rd rib cartilage just medial to the breast tissue being removed and just lateral to the sternum. This allows for better return of nipple sensation.

4. Which of the breast reconstruction procedures results in the least scarring?

Answer: By far the best result and state of the art today involves Nipple Sparing Mastectomy(NSM) and immediate reconstruction with DIEP or other Perforator flaps. For an optimal outcome, it is crucial to have a breast surgeon well trained in NSM and the right plastic surgeon. Ideally a one stage mastectomy and reconstruction can be done. Typically the breast would have a faint scar on the under surface of the breast. The DIEP donor site should be the same as a cosmetic tummy tuck. If the abdomen is not a good option, skin and fat can be obtained from the posterior thigh leaving a scar concealed in the fold beneath the buttock. This is my most recent innovation and is called the PAP flap.

5. Of all the different types of breast reconstruction you have performed, which have you had the most success?

Answer: A Plastic Surgeon moves tissue around to restore form and function. Using microsurgical technique allows us to move tissue from anywhere to anywhere in the body creating more options to choose from for a particular patient. Microsurgical transfer of tissue for breast reconstruction has the highest success rate over any other method. Traditionally the drawback of this technique is that it requires specialized training in microsurgery. Special equipment is needed, and the length of the procedure may be longer than other methods. By specializing in microsurgical breast reconstruction, I have greatly reduced the OR time, decreased the complication rate, and increased success rate. Success rate with DIEP breast reconstruction is over 99%. These advances make the patient’s decision to select this procedure with the most natural, permanent result easier.

6. How did you come up with the idea for the DIEP breast reconstruction procedure?

Answer: My mother was diagnosed with breast cancer 23 years ago. My father, a General Surgeon, recommended a mastectomy. My mother was very active and particularly enjoyed water sports. She did not want to lose her breast, and if that were necessary, would desire reconstruction. I was put in charge of the breast reconstruction and planned a possible pedicle TRAM flap procedure knowing my mother would miss the function of her rectus abdominus muscle. Fortunately margins were clear on re-excision of the cancer and she was treated with lumpectomy and radiation. After this I was determined to develop better options for breast reconstruction. By studying the blood supply to the skin and fat of the lower abdomen, I discovered how to reliably transfer only the skin and fat without muscle sacrifice using microsurgical technique. Thus was born the whole field of Perforator flaps for breast reconstruction starting with the DIEP flap.

Click here to view Dr Robert J. Allen Curriculum Vitae.